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NEW PATIENT QUESTIONNAIRE PERSONAL DATA SURNAME FORENAME(S) DATE OF BIRTH SEX (PLEASE TICK) HOME TELEPHONE MOBILE PHONE EMAIL (IF YOU INCLUDE THIS WE WILL ASSUME THAT YOU HAVE GIVEN YOUR CONSENT ANY OTHER CONTACT NUMBERS – EG WORK MALE FEMALE TO BE CONTACTED BY THIS METHOD) PLACE OF BIRTH RELIGION ETHNIC STATUS (EG – WHITE BRITISH, IRISH, CHINESE) MAIN SPOKEN LANGUAGE MARITAL STATUS (PLEASE TICK) EMPLOYMENT STATUS (PLEASE TICK) OCCUPATION OR STUDY DETAILS CURRENT GP (NAME) SINGLE MARRIED DIVORCED WIDOWED CIVIL PARTNERSHIP STUDENT EMPLOYED RETIRED UNEMPLOYED OTHER SURGERY ADDRESS NEXT OF KIN RELATIONSHIP TO YOU ADDRESS (IF DIFFERENT FROM ABOVE) PHONE NUMBER MEDICATIONS NAME(S) OF ANY MEDICATIONS WHICH YOU TAKE REGULARLY, THEIR STRENGTH AND DAILY AMOUNTS (if you have a repeat slip from your previous practice – please attach) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. REGISTERED AT A LOCAL PHARMACY □ YES OR □ NO NAME OF PHARMACY : IF YOU HAVE COPIES OF ANY IMMUNISATION/VACCINATION RECORDS – PLEASE ATTACH THESE (OR WE CAN TAKE A PHOTOCOPY) ALLERGIES 1. 2. 3. PAST MEDICAL HISTORY PROBLEM/CONDITION PLEASE TICK PROBLEM/CONDITION DATE OF DIAGNOSIS HEART ATTACK ASTHMA ANGINA COPD (CHRONIC OBSTRUCTIVE AIRWAYS PLEASE TICK DATE OF DIAGNOSIS DISEASE HIGH BLOOD PRESSURE CANCER DIABETES EPILEPSY STROKE/TIA PHYSICAL DISABILITY LONG TERM SICKNESS MENTAL HEALTH PROBLEMS DRUG ABUSE DEPRESSION PLEASE GIVE DETAILS ANY OTHER MEDICAL CONDITION ANY OPERATIONS AND THE YEAR PERFORMED YEAR SOCIAL AND PERSONAL HISTORY EXERCISE GRADING PLEASE TICK APPROPRIATE ENJOY LIGHT EXERCISE MODERATE EXERCISE HEAVY EXERCISE EXERCISE GRADING PLEASE TICK APPROPRIATE COMPETITIVE ATHLETE EXERCISE IMPOSSIBLE AVOIDS EXERCISE SMOKING STATUS NEVER SMOKED EX – SMOKER DETAILS OF WHEN STOPPED CURRENT SMOKER DETAILS OF AGE STARTED AMOUNT SMOKED AMOUNT SMOKED ALCOHOL PLEASE COMPLETE ADDITIONAL FORM IN PACK FAMILY HISTORY MEDICAL CONDITION HEART ATTACK ANGINA BREAST CANCER BOWEL CANCER DIABETES PLEASE TICK RELATIVE/RELATIONSHIP TO YOU AGE AT DIAGNOSIS FEMALES ONLY LAST SMEAR (APPROXIMATE YEAR AND RESULT) NOT APPLICABLE (PLEASE TICK) CONTRACEPTION HAVE YOU HAD A HYSTERECTOMY ? YES NO OBSTETRIC HISTORY ARE YOU CURRENTLY PREGNANT TIMES YOU HAVE BEEN PREGNANT (PLEASE TICK) YES NUMBER OF LIVE BIRTHS NO MENOPAUSE & HORMONE REPLACEMENT THERAPY (HRT) ARE YOU ON HRT ? AGE OR YEAR YOU STARTED ON ABBEY MEDICAL PRACTICE NEW PATIENT QUESTIONNAIRE OCT 16 YES HRT NO MEDICATION NAME COMMENTS
